Day 1 – Assess disease severity and assemble the team
Obtaining a thorough clinical history is essential to classify disease severity and identify potential triggers for the acute exacerbation. Potential triggers may include infections, new medications, recent antibiotic use, recent travel, sick contacts, or cessation of treatments. Standard questions include asking about the timing of onset of symptoms, bowel movements during a 24-hour period, and particularly the presence of nocturnal bowel movements. If patients report bloody stools, inquire how often they see blood relative to the total number of bowel movements. The presence and nature of abdominal pain should be elicited, particularly changes in abdominal pain and comparison with previous disease flares. These clinical parameters are used to assess response to treatment; therefore, ask patients to keep a log of their stool frequency, consistency, rectal urgency, and bleeding each day to report to the team during daily rounds.
For patients with ASUC, a full colonoscopy is rarely indicated in the inpatient setting because it is unlikely to change management and poses a risk of perforation.11 However, a sigmoidoscopy within the first 24 hours of admission will provide useful information about the endoscopic disease activity, particularly if features such as deep or well-like ulcers, large mucosal abrasions, or extensive loss of the mucosal layer are present because these are predictors of colectomy.8 Tissue biopsies can exclude cytomegalovirus (CMV) infection, an important consideration for patients on immunosuppression including corticosteroids.12-16
Venous thromboembolism (VTE) prophylaxis is extremely important for hospitalized inflammatory bowel disease (IBD) patients. At baseline, IBD patients have a threefold higher risk of VTE than do non-IBD patients, which increases to approximately sixfold during flares.17 Pharmacologic VTE prophylaxis is recommended for all hospitalized IBD patients, even those with rectal bleeding. This may seem counterintuitive in the setting of “GI bleeding,” so it is important to counsel both patients and team members regarding VTE risks and the role of the prophylactic regimen to ensure adherence. Mechanical VTE prophylaxis can be used in patients with severe bleeding and hemodynamic instability until pharmacologic VTE prophylaxis can be safely initiated.17
Narcotics should be used sparingly for hospitalized IBD patients. Narcotic use is associated with greater likelihood of subsequent IBD hospitalizations, ED visits, and higher costs of health care for patients with IBD.18 Heavy use of opiates, defined as continuous use for more than 30 days at a dose exceeding 50 mg morphine per day or equivalent, was strongly associated with an increased overall mortality in IBD patients.19 Opiates also slow bowel motility and precipitate toxic megacolon, along with any other agent that slows bowel motility, such as anticholinergic medications.8 These agents may also mask bowel frequency symptoms that would otherwise indicate a failure of medical therapy. Similarly, use of NSAIDS should also be avoided because these have been associated with disease relapse and escalating intestinal inflammation.20